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Evidence summaries

Drugs for Ventricular Rate Control in Atrial Fibrillation

Calcium-channel blockers verapamil and diltiazem, or select beta-blockers, are effective for heart rate control at rest and during exercise for patients with atrial fibrillation. Level of evidence: "A"

A systematic review 1 included 45 studies with a total of 2 059 subjects. The authors conclude that the calcium-channel blockers verapamil and diltiazem, or select beta-blockers, are efficacious for heart rate control at rest and during exercise for patients with atrial fibrillation, without a clinically-important decrease in exercise tolerance. Selected beta-blockers, such as the non-cardioselective beta-antagonist nadolol or the second-generation beta-1-antagonists atenolol and metoprolol, are efficacious at rest and with exercise. There is some evidence, however, that beta-blockers cause a transient decrease in exercise tolerance. Digoxin is useful when rate control during exercise is less of a concern.

According to the 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation 2 pharmacological rate control can be achieved with beta-blockers, digoxin, diltiazem, and verapamil, or combination therapy. The choice of rate control drugs depends on symptoms, comorbidities, and potential side-effects.

    References

    • Segal JB, McNamara RL, Miller MR, Kim N, Goodman SN, Powe NR, Robinson K, Yu D, Bass EB. The evidence regarding the drugs used for ventricular rate control. J Fam Pract 2000 Jan;49(1):47-59. [PubMed]
    • Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021;42(5)373-498. [PubMed]

Primary/Secondary Keywords